THE DIFFICULT SALE
Crime and punishment at an opioid startup
By Evan Hughes
The pharmaceutical industry is going through a very good crisis. The rapid development of safe and effective Covid-19 vaccines and treatments has made pharmaceutical companies acclaimed heroes. Chipper executives brag about saving billions of lives. Shareholders swim in profits.
It’s a remarkable turnaround for an industry that has been widely reviled. Prepandemic drug companies were routinely berated for the excessive prices they charged for drugs developed with taxpayer support. They were dragged before grand juries for their roles in what, until the onset of Covid-19, was the country’s most pressing public health crisis: the opioid epidemic.
Even though it has been overshadowed by the coronavirus, the opioid crisis has gotten worse. In the most recent 12-month period for which data is available, more than 100,000 Americans – a record number – died from overdoses. Many were killed by fast-acting synthetic opioids such as fentanyl, which is found in illegal street drugs and prescription painkillers.
Anyone who has read “Empire of Pain,” Patrick Radden Keefe’s epic exposé about the Sackler family behind Purdue Pharma, knows the dirty hands of opioid peddlers. But until I read “The Hard Sell” about the outrageous behavior of an obscure pharmaceutical company, I hadn’t appreciated the full extent of the filth or dark stain the opioid sector has left on the entire industry.
“The Hard Sell”, by journalist Evan Hughes, is a quick and maddening report from Insys Therapeutics, whose entire business model seemed to revolve around crookedness. (The book is based in part on a 2018 article Hughes wrote for DailyExpertNews Magazine.) The only branded product was Subsys, a fentanyl-based liquid that patients sprayed under their tongues. Insys executives made extraordinary — and sometimes criminal — efforts to get their addictive and dangerous drug into as many mouths as possible.
The company was founded in Arizona by “an Indian-born visionary,” John Kapoor. He was an entrepreneur of a serial pharmaceutical company that, despite repeated fights with regulators, investors and business partners, managed to come forward time and again, with his fortune and reputation largely intact. (A judge found that one of his early companies, as Hughes puts it, was “full of misconduct,” and the Food and Drug Administration reprimanded it for endangering patient health.)
Kapoor is cut from a mold that will be familiar to readers of “Bad Blood” or “The Cult of We” (about the Theranos and WeWork debacles, respectively). He was blindly ambitious, with a sympathetic origin story that disguised his broken moral compass. While Elizabeth Holmes would tell people she started her pinprick blood-testing business because she was afraid of needles, Kapoor claimed to have come up with the idea for Subsys after watching his wife endure excruciating pain as she died of breast cancer.
Hughes is skeptical about this cover story. The most likely explanation, he suggests, is that Kapoor discovered a lucrative opportunity to jump into the booming opioid market with a newfangled narcotic.
The innovation with Subsys was not the drug itself – the active ingredient, fentanyl, has been around since 1960 – but the delivery mechanism. There was an arms race to develop the fastest-acting opioids. Spraying fentanyl molecules under your tongue proved to be a super-efficient way — “near the rate of IV drugs given in a hospital,” Hughes writes — to provide pain relief.
Kapoor’s company has received FDA approval for Subsys to be used as a treatment for cancer patients. But that was a limited and already busy market. From the beginning, Insys’ goal was to tap into the much larger group of people who suffered from a wide variety of pains. To do that, Kapoor and his team at Insys borrowed tactics from their rivals and exploited the quirks of the pharmaceutical industry.
The company bought access to pharmacy data showing which doctors were prescribing many fast-acting synthetic opioids. About 170 doctors across the country accounted for about 30 percent of all prescriptions for these drugs, and Insys sent its sales force to convince this small group of like-minded doctors to prescribe Subsys. (Yeah, it’s crazy that drug companies get access to this kind of easy-to-misuse data.)
To allow for even more precise targeting of receptive physicians, the FDA required drug companies like Insys to closely monitor who was prescribing their drugs. “The purpose of collecting this data was to protect patient safety, but Insys was in a marketing goldmine,” Hughes writes. Soon, doctors prescribing Subsys began to find Insys vendors in their offices, pushing them to write more scripts.
Insys’ sales team initially tried to point out Subsys’ merits, but there was a problem: Competitors showered this small group of doctors with free meals, gifts, and money. To succeed, Insys had to play the same game.
Bribery is frowned upon, so not only were the doctors cheated on food, drink, and fun, they were also paid to deliver speeches about Subsys to small audiences — sometimes to the staff of their own offices. “The idea was to funnel cash to the speaker so that he would prescribe Subsys in return,” Hughes writes. “If he didn’t keep his appointment, he wouldn’t be paid to speak anymore. It was a return.”
The entire opioid trade seems to have been overrun by these underhanded tactics; as Hughes points out, “Nothing Insys did was really new.” Indeed, the most surprising and powerful thing about “The Hard Sell” isn’t the criminality of one company – we’ve grown accustomed to companies behaving badly – but how institutionalized these practices were in the modern drug industry.
This was very profitable for Insys and its top managers. The price of some Subsys recipes ran into the tens of thousands of dollars. (As insurance companies began to hesitate to cover these costs, Insys established a central office to secretly file and process paperwork on behalf of physicians.) Insys went public in 2013 and was the top-performing IPO of the year, by more than quadrupling the share.
By this time, even as Wall Street and the corporate media were celebrating Insys, the wheels were starting to come off.
Conscientious insiders warned the government about the company’s fraudulent and abusive practices. Soon, federal investigators got closer. Kapoor and his inner circle are said to be the rare business leaders who would face criminal charges. Hughes talks about the chase and the trial in a dramatic way.
My only major complaint about “The Hard Sell” is that it’s unclear how much damage Subsys has done in the context of the wider opioid epidemic. Hughes has stories of people overdosing and becoming addicted, of lives and families being destroyed, but I wasn’t sure if prescription drugs like Subsys were the root cause of the fentanyl crisis, a contributing factor, or a pointless blip.
Sometimes I wondered if the answer could be the latter and if Hughes was dodging an inconvenient fact so as not to deflate an otherwise compelling story. If so, he needn’t have worried. Even if Insys proves to be a footnote in the opioid epidemic, there is value in exposing the world to the sordid underbelly of a powerful industry — especially one that has become the sudden object of so much public gratitude.